HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Women's Health Across the Lifespan

SARALYN MARK: Good morning. I am so delighted to be here to join you at this very important meeting in Washington, D.C., my own home town, and to have an opportunity to work with Sabrina again. It's been a lot of years, we have done a lot of interesting things; and to be able to speak with you today about some of that is an added highlight.

Sabrina mentioned that I do work with NASA, and I have been with them for about seven and a half years. I advise on issues regarding women's health, sex and gender based medicine, other critical issues that hopefully we're going to address as we go back to the moon and Mars.

But I am reminded of a couple questions Sally Ride was asked when she was getting ready to fly in 1983. She was of course our first female astronaut in space.

I kid you not; she was asked these very important questions: One, with space travel does cellulite get better; do wrinkles improve; and do you get taller? And one about having to wear a bra, but I won't even go down that point.

SARALYN MARK: And the answer to all those questions of course was yes, yes, and yes. And I kind of laugh thinking, okay, that was about 22 years ago, but also often when I travel the country I'm asked about that, as well; so even though we have made tremendous progress, we still go back to our basic elements of what it is that we need to live happy and live healthy.

Fortunately today, we're going to talk about substance. I have a little bit of time with you and I want to share with you issues that we address when we talk about health care across the lifespan, and I'm going to do it from a woman's health prospective.

I also want to share with you some of the exciting programs that we have created through the department, perhaps highlight a few that NASA has done as well. I'm going to highlight one program that is very close to my bones, to use that pun, and that is the National Bone Health Campaign. And then we're going to end with some future trends that I think are going to affect all of us as we age and as we grow older in this country.

Now, often when I go into my practice up at Yale, I'm sometimes asked by parents what can I do to help my daughter's health. What are activities that I can do that we can share together? And we talk about exercise and running and taking a walk. And then I look at the young girl in the room, and I see that she's got sort of a bland face, and then I say go shopping. And I see the room light up.

And it was funny because as an endocrinologist I wanted to know from a hormonal viewpoint why is shopping beneficial to our health, and there is a lot of benefit. How many of you like to shop? Excellent. And I know some of the men do, too. I do. Home Depot. Do I need to say more? Yes.

SARALYN MARK: Just as a side note, I have to mention it because my husband, who has been deployed, is coming back today. Right before he left he said you know you talk about heart health so much and physical activity, this is your birthday present. And I kid you not, he bought me a lawnmower.

SARALYN MARK: He did. And I got to use it all summer. So he's very conscious of my heart health.

But in regard to shopping, there are benefits. If you have a great sale, you are moving very quickly, there is aerobic conditioning, very good for you. You drop your cortisol levels, blood pressure improves.

If you get a lot of stuff, you've got weight bearing activity, yes, so there is decreased bone absorption. And for young girls bone formation here improves.

And then what we tend to do is we do it in groups, and we have seen that oxytocin levels actually go up; that sense of well‑being drug.

So overall I think probably the one thing we could advocate from the government is to provide us tickets so we can go shopping. But independently of that, hopefully that's not going to be quoted here today, we have had to really look at women's health from many different vantage points.

It's so easy I think from academia for where we sit within our state and federal government to recommend proposals and to recommend activities, and yet we're not really aware of what our patients, what our constituents, what our population really needs.

Now, in 15 years we have made tremendous progress. 15 years ago we really didn't talk about women's health, there were very few women's health research studies. Part of the reason it was so difficult we were told to get women engaged in studies. One, we needed to protect the fetus; two, women were too busy; and, three, weren't they just little men? And the answer to that of course is no.

We have created offices in women's health throughout the federal government. You are familiar with the HRSA office, certainly the National Institutes of Health have played an important role. They were established in 1990.

The office that I serve at, HHS, is the office on women's health. We were established in 1991 to really work with all of you, to really coordinate a comprehensive women's health agenda, and to work with organizations that could help us in the fill to get our messages out.

We have seen offices in FDA, CDC, Indian Health Service; and I could go on and on, and we certainly have worked with our Regional Women's Health Coordinators. And this has played an important role because again we needed to make sure that our messages from the federal level really get down to the state and local levels.

Now, what are some of the issues that we are concerned about? You can imagine as we travel the country what we are often told. What would you think? Breast cancer. We have made so much tremendous progress in that realm, at least in certain areas, that I think we have negated at times that heart disease, cardiovascular disease is actually the leading killer for women and men in this country.

Now, I trained at a tiny little hospital called Bellevue in New York City. And I think all of us, if you just sit back and think for a moment, what were your moments of epiphany, what really changed your life, what took you in the direction that you are doing things today.

I had a moment when I was in the emergency room at Bellevue Hospital, and I had a middle‑aged woman, I guess that's all relative today, a young woman, she was in her 50s, and she came in, she was a Latina, and she kept saying oye, oye, oye. And I remember that. And she kept pointing to her jaw.

And my chief resident at the time said she's anxious, give her the milk shake, that's what we called it, and it was Valium and Mylanta. I don't know how many of you ever prescribed that. It's very effective. Your patients will no longer complain, because when you give 10 milligrams of Valium no one is going to complain, they are asleep practically. And of course it calmed her down, and we sent her out, and she came back about five hours later in full cardiac arrest.

And for me that really played an important role that woman present differently, not atypically. When I hear that word atypical for women, I really get angry because what is considered the gold standard? Is man the gold standard for his symptoms? No. We all have our own uniqueness.

And again, I'm just ‑‑ and I know you're all familiar with it, but the typical symptoms in women can be nausea, can be vomiting, can be shortness of breath, can be jaw pain. Occasionally they will get that pain substernal chest pain, but again, the symptoms may not be what we traditionally read in the textbooks.

So with that, we have seen over 500,000 women die each year of cardiovascular disease, and yet we know that it's often a disease that we can prevent and the beginnings are often in childhood.

And I know all of you have tried to create programs looking at physical activity, looking at nutrition, looking at tobacco sensation. Let's think about tobacco, for example, number one preventable cause of death for people in this country.

I have never seen any good reason why we need to smoke. I don't know, have any of you? It is just remarkable that we still even have people thinking about it today, and part of that is due to our advertising. We have young girls going to tobacco because they think it keeps their weight down and it's an effective tool.

I know all of us have gone to schools and to shopping centers and seen young people with cigarettes, and yet we know if you can keep them from smoking and you can keep them at least until the age of 19, 20, most likely they will not start.

You look at the issues of obesity, and I am sure over the last few days you have talked about that, again not too far behind tobacco. And when you think about 9 million children overweight or obese in this country, what is our legacy?

We have done tremendous good with new technologies, we all have. But you ask someone, for example, to turn off a TV set and get up and do it, people wouldn't know how to do it today, they'd look at it and they would think where? Where is the clicker?

You know, and this is what we have done, we have got a generation now of children who have become so technologically adroit that often when they don't have that technology, they don't know what to do.

I remember about two years ago we had Hurricane Isabella hit the DC area, and they had a story in the Washington Post that we, of course, didn't have power for a week, and the children were complaining because they didn't know what to do. They didn't know how to play outside. They never heard of jump rope for example, or hopscotch, things that we, activities that we did as children.

So again, a generation of overweight and obese children will lead to a generation of overweight and obese adults. And when we talk about cardiovascular disease which is at epidemic proportions today, I can only imagine 10, 20 years from now.

We also have talked about cancer. And when we talk about women's health, I think we have done a fantastic job putting an imagine to breast cancer. We have our pink bracelets, we have our marches, we have our walks. Women are willing to come forward and talk about it; men are willing to come forward and talk about their wives' reactions and what they have experienced as well.

But we haven't put that face to lung cancer, and yet we know that is the leading cancer killer for women in this country. It surpassed breast cancer in 1987.

What we are appreciating is that women may present a little differently with lung cancer compared to men again. There may be different types of lung cancer, a different reaction to chemotherapy. We are trying to unravel why. It may be due to the estrogen effect and the role estrogen plays in neutralizing or activating enzymes that can neutralize or inactivate the carcinogens in tobacco smoke.

We know that women are more susceptible to passive smoking and higher development of cancer from that.

And these are important issues that we have to look at. I think when Christopher Reeves' widow developed lung cancer, it stopped people in their tracks because they thought, wait a minute, she's young, she wasn't a smoker. It got people thinking. And unfortunately sometimes that's what we need to be able to generate the energy and the drive to explore these issues further and to get messages out.

We have so much that we could talk about. We have osteoporosis, a disease that's very close, as I mention, partially because it runs in my family.

Over the last month I have been dealing with a mother who broke her hip. We used to kid her that she had so much padding that she would never do that. She smiled and told us anyone can break their hip. And we see that not only in women but we see it in men as well.

Osteoporosis is an interesting disease. We have called it a pediatric disease with geriatric consequences. Many folks don't know that you build about 90 percent of your bone mass by the time you are age 20; half of that during adolescence. That window of time, that 9 to 12 years, is so, so important, and yet we are not really talking about it.

And what I'm going to do in a few minutes is share with you a campaign that we have developed to try to address some of those inequities.

I can talk about domestic violence, we tend to think about it as a young woman's issue, there is an intergenerational approach. As a geriatrician, I have visited many nursing homes and have seen abuse in elderly. Often it is done by family members, sometimes it's done just because of a lack of caring, but we do see it across the generations.

And certainly another important area that we need to think about is mental health issues. Women are twice as likely to be diagnosed with depression but only a quarter are properly diagnosed and only a quarter are appropriately treated.

Again, we are beginning to appreciate the gender components to the development of effective disorders and how men and women respond. So I think this is another important area.

Now with that, it sounds like doom and gloom, and it's too early in the morning for that, much too early. There's been a lot that we have done, and just for a few minutes I want to highlight some exciting programs.

First of all, we have create the National Women's Health Information Center. How many of you have actually gone to it? Excellent.

This center is easy to reach. We have an 800 number, 1‑800‑994woman. The website is the Woman's Health.gov website. You can get it many different ways. It can be www.4woman.gov, or you can just put in women's health.gov.

It is our site. The site has over 800 topics. There is a section on men's health. The information on the site has been vetted. It is clear, it is understandable, and it is a site that is constantly being updated. And what I like about it, I don't know about you, but sometimes you will have patients come to you and they will find something on the Internet, and they will say it must be true, it was on the computer.

And for some reason that screen adds a bit of credibility. What I love about this site is that there's nothing to sell, the information is based on evidence, based on ground science, and it's a good tool. And I highly recommend all of you go to it.

We have also created National Centers of Excellence in academic centers as well as community centers in rural areas around the country. The Office of Women's Health as created over 43 to date.

The centers are really exciting because they provide multi‑disciplinary care, they provide opportunities for research, opportunities for education, and they are wonderful resource for all of you in your states; and I hope many of you have these centers and you use these centers as a source of information and as a tool for you to get your messages out.

We have also created educational programs in heart disease. If you go to that Internet site, what I just mentioned, we have an interactive tool so that women can actually assess what their cardiovascular risk is and actually look at interventions that they may take.

Well, with that, I just want to talk to you for a few minutes about osteoporosis. How many of you have osteoporosis programs in your states? Excellent. I'd love to see next year or two years from now every one of you raise your hand because a lot of messages that we have used to talk about osteoporosis actually resonate with everything we need to talk about. We're actually talking about disease prevention here.

This program was created in partnership with the National Osteoporosis Foundation and with the Centers for Disease Control, CDC. It's a multi‑year national social marketing campaign. The initial focus was girls 9 to 12, again because we knew we had a window of opportunity to reach young girls and hopefully begin to shape their awareness and certainly their behavior.

We also wanted to target adults and others who influenced them. Now, you see the icon on the right, and that is Carla, and Carla in German actually means strong or powerful, and she was developed after we went to many different focus groups and asked young girls what do you want to hear? What do you listen to? And they say we don't listen to celebrity spokes people, we want to listen to our own peers.

This program was authorized by congress in 1998, and it's an important program because when you think about osteoporosis, it affects over 42 million Americans in this country, and over 80 percent of whom are women. We also know today about 14 billion dollars in expenditure. Perhaps in the next 15 years that number will go up to well over 60 billion. We know hip fractures are actually the leading cause of institutionalization for people in this country.

Now, what we have learned about current behavior is a bit sobering. As I mentioned to you earlier, young people often don't know about physical activity or even want to engage in it. It's certainly a problem as we cut physical activity in our schools. I've been told it's just because it's just too busy in a day; we don't have time.

Unfortunately, we will have generations of young people affected by cardiovascular disease and by osteoporosis because of that.

We see for young girls that they do relatively well around eighth and ninth grade, but their physical activity level start to level off by about 12th grade and then less than 50 percent by the time they even enter into college, and that number may go down.

When we look at meeting calcium requirements, it's even more sobering. Only about 20 percent of young girls get the amount of calcium they need in their diet. Some estimates are as low as 10 percent. So you can see that if we don't reach young girls today, we are going to have a generation of many broken bones.

What are some of the communication objectives? Well, they are very simple. We want to increase physical activity, we want to increase calcium consumption.

I think what we have seen is that we need to also influence and really encourage and convince parents and influencers that you have a say. I so often have mothers come up to me and say there's nothing I can do, and fathers. But our studies have shown that children will replicate their mother's behavior. In fact, we have even begun to see children replicating bulimia because they have seen that in their mothers.

We also know that father's play an important role certainly in regard to physical activity, and so this is extremely important to get both parents engaged.

Now, as I mentioned, we have many different focus groups. We talk to young girls all across the country. But what we found, again, was quite sobering. They have little knowledge of the health benefits of calcium. They felt that if you are healthy, that means you're happy, you're engaged, you are energetic.

Also parents felt they that they, as I mentioned, had little influence. They were also concerned they didn't have money to buy the food products that they need.

Also I would like to say that poverty perhaps is the greatest carcinogen. It's very hard when you go out there and you try to convince someone to eat a healthy diet and they come to you and say I have 5 dollars and I need to feed a family of five, so I'm going to go to a fast food restaurant and get that bucket of chicken because I just don't have the money.

Or they may come and say I don't have the time to prepare healthy meals. So we have to be cognizant of what the issues are that we need to engage and encounter to get these messages out.

Now, what we know is that, as I mentioned, some of the barriers that you need folks feel that you need large quantity of food, no time to make meals, lack of money, and the lack of perceived influence. And we are optimistic that we can change some of those barriers.

We have developed a lot of focus groups, as I mentioned, and what we equated for young girls is that power meant physical strength and self‑ confidence and self‑esteem. If you can change a way a young girl thinks about herself during these years, you can truly change lives. And this is one of our first tools to do it.

As I mentioned that we had significant outreach, we worked with the radio. We also have a wonderful website, www.powerful bones.com or.gov. You can go to the CDC website and link to it. This past year we launched the parent website, and you can actually order materials from this website.

As you can see, we have cartoons and drawings that I think really resonate with young girls. In fact, we found out that they used to collect the milk mustache posters, now they are collecting posters about Carla, and we're happy to see that.

We also are trying to link the intergenerational approach. We have found that parents have told us that as they educate their daughters about bone health they are learning about their own bone health. And I think that is, again, a double benefit.

As I mentioned, we have this website. It is updated quiet frequently. We have games and quizzes. We really are trying to reach young girls in the way that they need to learn. And what is exciting is parents, they can go on these websites with their daughters and help them as well.

Now, I'm often asked why don't you have it for boys. And part of the reason is we first needed to level the playing field. When we looked at our data, we found young boys were still engaged quite actively in some of the messages such as physical activity and calcium consumption. We have seen young boys drink the milk right out of the carton. And what we wanted to do is level the field.

But we are looking at phase two right now to engage boys when we know their influence is certainly of young girls. But we also want to make sure that we get messages that resonate with them so that we maintain a generation of healthy men as well;

As you can see, it's a fun site, it's one that I think you can use as a tool. I highly recommend that you think about ordering some of our tools because they are a great resource. We have won many awards for what we are doing. We have been told it's better than awesome, and I guess that's a great recommendation and a great review, and we definitely will take it.

We have reached millions of girls, but it's going to take your work and your effort to make sure that we go from 2 million to 20 million. And I think we can do it if all of you definitely use this resource.

Well, for just a few minutes I want to talk to you about some trends that we need to think about. In this morning's presentation I could go on about some of the other issues that we are concerned about. Certainly diabetes is one of them. Over 18 million Americans, many of whom don't even know it. We could talk about diseases. But I want to talk about more future trends.

We are seeing an increased use, for example, in the use of telemedicine and telehealth. It used to be only a few states really were involved in this area, now we see it across the globe. And it's an exciting resource, but we've got to be cognizant of the issues regarding liability, how do you keep the information confidential, what do you do about licensing?

And I think as we look at telemedicine, telehealth, it's a good tool, but we need to be aware of it and ahead of the game. As we're going more towards the electronic health record and we're hoping within the next 10 years to all be wired and we certainly saw the importance with the hurricane to have this information, I think we on the front lines need to be there discussing some of these key issues.

Another important issue in women's health is the use of complimentary alternative medicine or what I call traditional medicine. We know many people use it. I know many people, about 60 percent probably often don't tell their physicians what they are doing.

How many of you have ever used a supplement, yoga, massage. I mean, I could go down the list, so I'm sure all of you would raise your hands. So we know populations are doing this.

Fortunately we finally have studies to begin to look at the safety and efficacy certainly studies through the National Institutes of Health, but what I recommend is that we ask our patients, we ask our population what are you doing.

I had one woman come in, she was being treated for depression, we had her on an antidepressant. She went to a health food store and found St. John's Wort. She found it in had teabags and found you could just put it into your jello. And she came back, and she now was pregnant, even though she had been on birth controls, because of the interaction between St. Jones Wort and birth control pills. So she was very depressed at that point.

What I think it shows to us is that our public thinks of it as safe and natural, yet there are drug interactions. And because many of these products are protected under DSHEA, the Dietary Supplement Heath Education Act, we often don't really know what's in these products.

So I think it's important from a state level that we begin to talk about it and look at it, not only for reimbursement issues but making sure we get the appropriate messages out.

Another important area is the Human Genome Project. We have made tremendous strides to look at what makes us human. It doesn't take much, only about 25,000 genes. We're not too far off from being related to our ancestors, the monkeys. Someone once said that between us and a sponge there was only about five differences in genes. I like to think that there is more there.

But what we have realized is that we are so related, and we need to insure that as we do manipulation of our genetic code, as we begin to understand the genetic contribution to disease that we don't use it as a means for discrimination. And I think we are beginning to look at it but we need to be even more aware.

We're also looking at the impact in new technologies. I do work for NASA, and NASA certainly is very interested in nanotechnology which is technology at the billionth of a meter. We're using some of that technology today for example stain resistant pants and in drug delivery systems.

We eventually may be able to use that technology to manipulate the gene, to operate at the genetic level, to create artificial organs, for example. And I think that is all very exciting, but again we need to be sure we do it in a safe and efficacious way.

Another important area, one that I think we are going to be hearing more about, is the impact of sex and gender on human health. Now, do you think men and women think alike? You think they think differently? Yes. Well, they do, they do think differently, and there are many interesting exciting studies really looking at the differences between men and women.

The Institute of Medicine had a report three years ago Entitled Does Sex Matter? Overwhelmingly, of course, the answer was yes. What we have seen is that we constitute sex, we look at it at the most basic biological level. Every cell has sex. When we talk about gender, we're really talking about the psychosocial component what one views as being a female or a male.

Now, it's an interesting area. If we were to take white blood cells from a man and put it in a petri dish and white blood cells from a woman and put it in a Petri dish and expose it to an antigen, a foreign antigen, these blood cells would respond differently.

We have also seen in the last two to three years that about 10 out of the 12 drugs that were pulled off the market were more toxic in women. For example, the drug Seldane, I think some of you are familiar with that agent, it was an antihistamine, it created more cardio toxicity and more fatal cardio arrythmias in women.

Digitalis, the drug that we have used all the time to treat congestive heart failure, Harlan Cromwoltz at Yale has actually shown that it's more toxic in women and may actually exacerbate and cause more side effects.

When I mentioned the way men and women think, they do think differently. We have studies, PET scanning studies that have shown the corpus collosum in women is extremely active. Women are often using both sides of their brain, men tend to use one side, and what is the clinical correlate with that?

We have seen after a woman has had a stroke, she may regain her speech a little quicker. So again, an interesting avenue.

I'd like the say that men and women also process information quite differently, especially when it comes to directions. How many of you ever asked for directions?

But again it's how we view the world. And it's sort of a funny story. About a year ago ‑‑ my boss at NASA is a retired Air Force colonel, and we were down at Spellman College giving some lectures, and we were driving back to the airport, and I was given a sheet of paper about how to get back to the airport, and it was the typical direction, go three miles east, two miles north, make a turn at the Arby's, when you see the drug store go left.

He took out, I kid you not, his GPS device and put it on the windshield.

And men and women tend to look at it ‑‑ and the studies we have done for NASA really is interesting how men tend to like latitude, longitude numbers; women are more verbal in looking at directions. The funny think is we got lost.

SARALYN MARK: So I don't know what that makes out of any of us. I guess it's the great equalizer.

But it was an interesting review, and we're really starting to move into that area now when we look at research. Certainly the National Institutes of Health have had guidelines, the mandates since 1993 that men and women have to be included in clinical trials, and we have to do analysis by sex and gender.

And I think you are going to see within the next three to five years a lot more of how that's going to translate into care. The National Institutes of Health just recently, actually in the past week, has come out with some new programs to translate that research into effective tools for us in our everyday care of our patients. So I think you're going to see sex and gender put into what we do.

Well, in closing I'm reminded of a comment made by Edward Alby. He said sentiment without action is the ruin of the soul. And I think that is so true. I know what all of you do is so, so important.

We live in a bit of a challenging team. I know from the Federal Government we're constantly being evaluated. We call it being parted, being evaluated and assessed by our results.

And when we talk about prevention, and disease prevention especially, it's really hard because when you are looking at it from an intergenerational approach what you are doing today is going to set the groundwork and the health for generations to come. So it's very difficult to actually assess that, to look at the quantitatively. Intuitively we know we are doing the right thing, we believe it.

And with that, I want to leave you with those words of encouragement. Even though we may not have the metrics immediately today, we may not have the exact numbers to demonstrates our efficacy, we have to believe in what we are doing, because not only is our country depending on us today but the generations, the generations to come.

And with that I thank you, and I look forward to joining you in that march. Thank you.